Routine inspection·November 15, 2024

Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator, Donald Barber and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) licensed capacity for (185) current census (131). The facility has (166) apartment bedrooms with bathrooms included, reception area, library room, beauty/barber room, billiard room, (4) laundry rooms, offices, card room, media room, regency room, craft room, bistro room, lounge, exercise room, club room, garden room and a handicap bathroom. LPA was accompanied by the Administrator to conduct a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 73, 74 and 73 degrees fahrenheit. Water temperature measured at 118, 112.8, 120, 116.1 and 115.7 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating fire extinguishers, smoke detectors, signal alarms and carbon monoxide alarms. Posters such as personal rights, CCL complaint poster, CCL license, ombudsman, and facility sketch were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept in Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed resident files for admission agreements, physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA audited medication and observed that medication did not match medication records. LPA observed that the facility did not have the physical supply of PRN according to the resident's medical record. Deficiency issued. LPA reviewed the infection control plan, liability insurance, disaster drills and emergency disaster plan. One deficiency was cited during this visit. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D and appeal rights were discussed and provided to Administrator, Donald Barber.